DISCRIMINATORY HARASSMENT COMPLAINT FORM

Michigan Department of Community Health

1. Complainant’s Name (Print or Type) / 2. Race / 3. Gender / 4. Employee I.D. Number
5. Address / 6. City / 7. State / 8. Zip Code
9. Work Phone / 10. Home Phone / 11. Bureau/Region/Office/Division / 12. Work Hours
13. Bargaining Unit / 14. Immediate Supervisor / 15. Supervisor Work Phone
16. Accused / 17. Race / 18. Gender / 19. Bureau/Region/Office/Division
20 Accused Work Phone / 21. Bargaining Unit / 22. Immediate Supervisor / 23. Supervisor Work Phone
24. What is the relationship of the accused to the department? contractual, vendor, employee, etc…______
25. What is the relationship of the complainant to the department? contractual, vendor, employee, public, etc…______
26. Discriminatory Harassment Factors
Indicate which factor(s) you believe the actions were based upon. Check all that apply.
Age Color Disability Race
Height Weight Marital Status Genetic Information
Sex Religion National Origin Partisan Considerations
Sexual Orientation Gender Identity Other______(specify in detail below)
27. Choose Category:
Hostile Work Environment Quid Pro Quo
28. Please list any witnesses and contact information (additional pages may be attached if necessary).
Name / Name
Name / Name
29. Have you discussed this incident with anyone? No Yes If Yes with who and date(s)
30. Have you filed a grievance regarding this situation? No Yes
31. Have you asked that the behavior stop? No Yes If Yes, when?

Discriminatory Harassment Complaint Statement

32. Describe below in detail the alleged discriminatory harassment. Use additional pages as needed.
See page 3 for instructions.
I certify that the information provided is true, accurate, and complete to the best of my knowledge and belief. /

Employee Signature Date


Discriminatory Harassment Complaint Report Instructions

General Instructions

This form may be downloaded from the Intranet and must be completed by MDCH employees, customers, contractors, vendors, or members of the public who wish to file an internal complaint of potential violations of Discriminatory Harassment. Assistance in completing this form may be obtained from a harassment coordinator, supervisor, union steward, or the Equal Employment Opportunity Officer. Please ensure that the following information is submitted promptly following the alleged event, and record all information so that it is legible using type or block print.

1.  Complete items 1-32.

2.  Attach additional pages describing the alleged event(s).

3.  Sign and date the form and any additional documents submitted.

4.  Make a copy for your records.

5.  Forward your complaint of Discriminatory Harassment to:

Central Office send to EEO Officer.

Hospitals and Centers send to Harassment Coordinator, Hospital Director or EEO Officer.

6.  Submit your complaint to the appropriate authority as soon as practicable after the alleged violation(s).

7.  Refer to Discriminatory Harassment Policy DCH 4.1.13 for more information.

Investigative Process

A thorough investigation shall be conducted on all legitimate complaints of discriminatory harassment. The complainant shall provide the following information to the investigator to determine whether a full-scale investigation is warranted:

1.  Specific details as to what happened

2.  Who was directly or indirectly involved

3.  When the incident(s) occurred (date and time)

4.  Witnesses to the event(s)

5.  Documents or other evidence that may be useful to the investigation

6.  Why the complainant believes that their protected status, i.e. race, gender, age, etc., is the reason for the adverse action(s) or conduct

7.  How the treatment of the complainant differs from the treatment of other similarly situated employees who do not share the complainant’s protected status.

Retaliation Warning

Retaliation against anyone making a complaint, acting as a witness, or participation in the investigation is a violation of law and department policy, and is strictly prohibited. Retaliation complaints shall be investigated as a separate charge and persons found in violation may be subjected to discipline up to and including discharge.

Additional Assistance and Information

The Michigan Department of Community Health has an obligation to investigate complaints and take appropriate action even if the complainant does not wish to proceed with an internal investigation. The complainant’s identity and complaint may be subjected to disclosure pursuant to the investigation and resolution of the complaint.

You may also file an external complaint with the Michigan Department of Civil Rights within 180 days of the alleged incident; the federal Equal Employment Opportunity Commission within 300 days of the alleged incident; a grievance through your union or Civil Service; or file a private civil suit.

Information contained in this form will be kept confidential to the extent allowed by law, and as is practical to conduct a complete and thorough investigation.

If you have questions regarding this form or the investigative process, please contact Toya Williams EEO Officer for MDCH at 517-335-4276 or Deborah Crumbaugh, Bureau Director at 517-335-6762.

DCH-1012 Instructions 3/09

DCH-1012(E) (3-09) (W) Page 3 of 3